Acta Neurochir (Wien) (2008) 150: 733–735
DOI 10.1007/s00701-008-1591-0
Printed in The Netherlands

Brief Report of Special Case
Choreathetoid movement as an unusual presentation
of subdural haematoma
V. E. L. Young, G. Pickett, P. L. Richardson, P. Leach
Salford Royal Hospital, Salford, UK
Received 27 June 2007; Accepted 1 April 2008; Published online 30 May 2008
# Springer-Verlag 2008

Summary
Subdural haematomas can present with a wide variety of
symptoms. An atypical presentation can be movement
disorders. The key feature is that the history of onset is
more rapid than with neurological conditions such as
Parkinson’s disease. The symptoms can also be an acute
worsening of pre-existing disorder. The case discussed
involved an 80 year old woman with bilateral choreathetoid movements attributed to a unilateral chronic subdural haematoma. The haematoma was surgically drained
and the symptoms resolved. Sporadic reports of similar
cases of movement disorders associated with subdural
haematomas exist in the literature, but rarely do unilateral
haematomas present with bilateral symptoms. Pressure
effects, neurotransmitter abnormality and ischaemia have
been postulated as reasons for this type of presentation.
Unexplained and sudden movement disorders might
warrant imaging to rule out a subdural haematoma as
the cause.
Keywords: Choreoathetosis; subdural haematoma; movement disorder.
Case
An 80 year old woman presented with choreathetoid
movements and intermittent confusion. The movements
were bilateral, and more severe in the upper than lower

Correspondence: Mrs. G. Pickett, Salford Royal Hospital, Stott Lane,
Salford M6 8HD, UK. e-mail: gwynedd.pickett@srft.nhs.uk

extremities. Computed tomography (CT) imaging of the
head demonstrated a large isodense subdural haematoma
(Fig. 1), covering the whole of the left hemisphere, with
compression of the lateral ventricle and midline shift. The
haematoma was evacuated under general anaesthetic using
two burrholes. The movement disorder completely resolved within 48 h of surgery, although the confusion took
several days to improve. She was discharged back to her
home environment with some support.

Discussion
The earliest reported case of a subdural haematoma producing a movement disorder is the only other case in the
literature of a unilateral haematoma causing bilateral
symptoms. A 12 year old boy with acute lymphocytic
leukaemia developed a left sided chronic subdural haematoma (CSDH) and generalised chorea [2]. Upon evacuation the symptoms resolved.
In the few other documented cases of chorea=choreathetoid disorders associated with subdural haematomas, unilateral lesions were associated with unilateral
symptoms, whereas bilateral symptoms were typically
seen only in the presence of bilateral haematomas. In
1980, Bae et al. reported two cases of bilateral CSDH
causing generalised chorea [1]. The first was a 57 year
old lady who had been previously well and suddenly developed headache, dizziness and gait disturbance. During
admission she developed symmetrical choreiform movement that resolved completely on evacuation of bilateral
CSDH. The other patient, who had a family history of

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V. E. L. Young et al.

Fig. 1. CT showing large, isodense subdural collection over the left hemisphere
producing significant mass effect with
midline shift

Huntington’s disease, was admitted with headache, ataxia
and confusion. The choreiform movements became more
prominent during the hospital stay and there was a marked
improvement in symptomatology following drainage of
bilateral subdural collections. In 1981 a 73 year old man
presented with confusion and generalised chorea following recurrent falls during amputation rehabilitation [5].
The symptoms were attributed to bilateral CSDH seen
on imaging and there was complete resolution on evacuation. In 2004 a 76 year old women was also seen to develop choreiform movements that were ascribed to bilateral
CSDH [8]. She had been diagnosed with normal pressure
hydrocephalus two years previously and had undergone
insertion of a ventriculo-peritoneal shunt; the haematomas
were felt to have developed secondary to overdrainage
from the shunt. The right-sided haematoma was larger
than the left, and she underwent unilateral drainage which
led to complete symptom resolution.
CSDH have also been seen in relation to other movement disorders, reportedly causing parkinsonian symptoms, either de novo or as an acute exacerbation of
existing disease. There are two cases of parkinsonian
symptoms directly attributed to CSDH in the literature.
Both were initially thought to be Parkinson’s disease
and treated with L-dopa, without success. One patient
had a background history of mild Alzheimers disease
and presented shortly after a minor road traffic accident with shuffling gait and rigidity in the lower limbs
[7]. A unilateral CSDH was evacuated, leading to
recovery from the symptoms. The second patient was
found to have bilateral CSDH after being investigated
for headaches, confusion, tremor and gait disturbance
[6]. Again, drainage caused improvement in the clinical state.

Minor head trauma in two cases of known Parkinson
patients provoked a deterioration in their previously stable disease state. CT imaging demonstrated CSDH (unilateral in one, bilateral in the other). One patient made a
rapid recovery to their former level [3] whereas the other
improved but at a much slower rate [4].
The presentation of a subdural haematoma as a movement disorder is only found in the literature in case
reports. Clearly, any proposed theory of pathogenesis
must explain the production of bilateral symptoms by
a unilateral lesion. One theory postulated is that pressure effects cause transtentorial displacement of the
brain leading to damage to thalamic structures [1, 8].
Direct pressure on basal ganglia structures themselves
[6, 7] or altered neurotransmitter function have also
been suggested [7]. Another possibility is that the mass
of the haematoma produces ischaemia in the subthalamic nuclei [1, 5, 6]. There could also be a lesion in the
frontopontine pathways [6].
Movement disorders are a rare presentation of chronic
subdural haematoma. However, the sudden onset of such
symptoms may warrant CT scanning to rule out this potentially reversible cause. The diagnosis of CSDH should
also be considered in an acute exacerbation of a previously stable chronic condition.
References
1. Bae SH, Vates TS, Kenton EJ (1980) Generalised chorea associated
with subdural hematomas. Ann Neurol 8: 449–450
2. Bean CS, Ladisch S (1977) Chorea associated with a subdural
hematoma in a child with leukaemia. J Pediatr 90: 255–256
3. Chou SM, Gutmann L, Morgantown WV (2001) Deteriorating parkinsonism and subdural hematomas. Neurology 57: 1295
4. Harding AE (1984) Subdural hematoma in two patients with chronic
neurological disorders. BMJ 288: 1986–1987

Choreathetoid movement as an unusual presentation of subdural haematoma
5. Kotagal S, Shter E, Horenstein S (1981) Chorea as a manifestation
of bilateral subdural hematoma in an elderly man. Arch Neurol
38: 195
6. Sandyk R (1982) Parkinsonsim caused by chronic subdural haematoma. SA J Med 61: 595–596
7. Suman S, Meenakshisundaram S, Woodhouse P (2006) Bilateral
chronic subdural hematoma: a reversible cause of parkinsonism. J R
Soc Med 99: 91–92
8. Sung YF, Ma HI, Hsu YD (2004) Generalised Chorea associated with bilateral chronic subdural hematoma. Eur Neurol 51:
227–230

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Comment
The authors report the case of an 80 year-old female patient who
presented with bilateral choreathetoid movements caused by a unilateral
chronic subdural haematoma. These symptoms resolved after evacuation
of the haematoma. Although rare, this is a known possibility, particularly
when the development of the movement disorder is abrupt. As stated by
the authors, the exact pathophysiologic mechanisms remain hypothetical.
Alain Barth
Medical University of Graz